2011_1216CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK.FT..OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE: � L � � i ��' �� n � �'/-�� � �
The baci�Iow ptzvmtion assembly detailed below has bcm tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle c Pressure Vacurtm Breaker
Double Check Valve � Atmosphere Vacuum Breaker
Manufacnaer '� �l ���vj�/� Size � ! � ��
Model Number � �
Serial Number � � — � ` � �
Located AL .f �, � � �"
The above is certi.f ed to be true.
Firm Name 3�t
irtea+: dr�r.
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester �-� Lr' � '��/� /� ✓�
Cent Tester No. ? ' �' - - Date ` �- � G � �
Yellow -City Copy
Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFATtFR
Double Check Valve Assembly
1st Chec3c
2nd Cbecl:
Relief Valve
Air Inlet
Cheek Valve
Initial Test
DC- Closed
Tiahi_.. l
RP- G 2,' vsid
��� p
.Closed Tight �U�
Leaked o
v frr
Opined at
nsid
Opined at
nsid
Did not Opm O
nsid
Leaked �
Repaus
and
Materials
Used
Test Afirr
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
vsid
Opined at
nsid
vsid
RP sid
The above is certi.f ed to be true.
Firm Name 3�t
irtea+: dr�r.
Firm Address
Gauge #
Date last accuracy tested
White - Customer's Copy
Certified Tester �-� Lr' � '��/� /� ✓�
Cent Tester No. ? ' �' - - Date ` �- � G � �
Yellow -City Copy
Pink - Testers Copy